Moving away from the scarcity fallacy: three strategies to reduce the mental health treatment gap in LMICs
Authors: David M. Ndetei, Victoria Mutiso, Tom Osborn
Journal: World Psychiatry (2023)

The mental health treatment gap – defined as the difference between the number of people who have mental disorders and those who can access appropriate treatment – is estimated to be as high as 85% in low- and middle-income countries (LMICs), compared to only 40% in high-income countries (HICs)1. This high treatment gap in LMICs is unacceptable and represents an urgent global health priority. Here, we argue that possible solutions to reduce this gap do exist within many LMICs. Conventionally, we often blame resource scarcity for the higher mental health treatment gap in LMICs. This includes: a) human resource scarcity (shortage of specialized personnel), b) financial scarcity (income shortage at individual, family and national levels), and c) structural scarcity (e.g., concerning infrastructure, health systems, and policies)1. From our experience, we believe that this resource scarcity mindset is a fallacy. It is time to move away from this mindset if we are to minimize the mental health treatment gap in LMICs. Of course, it is true that, when compared to HICs, LMICs have a scarcity of mental health experts. But such an argument is based on the idea that the HIC model – where care is provided by "expert" caregivers such as psychiatrists and psychologists – is the gold-standard approach that LMICs must first attain to reduce the treatment gap. This Western/HIC model, however, does not often translate into accessible and effective care in LMICs2. Rather than focusing mostly on expert caregivers, LMICs should find answers to two important questions: a) what kind of human resources do we have in our hands, and b) how can we innovatively use these resources alongside the rather more expensive and relatively unavailable specialists? Indeed, there is a huge pool of utilizable human resources that can be trained to recognize symptoms of mental disorders, offer first aid psychosocial support, and refer upwards and accept referrals downwards for continued support. These include: a) families, that are traditionally the primary caregivers; b) individuals with lived experience, who can be supportive of people with mental disorders; c) an inexhaustible pool of clergy and traditional healers, who are often the first contacts for care even when specialists are available; d) community health volunteers, who are the backbone of community health services and the link between families, communities and community facilities; e) school teachers and counselors available in every school; f) peer counselors in schools, colleges and universities, who are trusted within their circles more than others outside those circles, including specialists; g) the nurses and clinical officers at community health service centers; h) general physicians working in communities. We have found that these different human resources can be expertly engaged to provide evidence-based interventions using the World Health Organization (WHO)'s mhGAP Intervention Guide (mhGAP-IG)3, and that peers – as young as 18 to 22 years – can provide evidence-based intervention in schools4. We, therefore, aver that in a way LMICs are not human resource poor, but rather that they have abundant resources which can be coopted into delivery of mental health services. As to financial scarcity, poverty at individual, familial and national levels often leads to inaccessibility of expensive psychotherapies and unavailability of psychotropic medications in LMICs. However, expensive psychotherapies can now be replaced by inexpensive ones delivered by trained lay providers5, and less costly generic medications are increasingly becoming available. Furthermore, a dialogue with families and patients should be encouraged about the costs of medications vis-à-vis what they can afford within their means, and when and where to seek help. As to structural scarcity, it is our experience that there is an oversupply of infrastructure that can be used, at almost no cost, for psychoeducation, treatment efforts awareness, prevention and rehabilitation in LMICs. These include: a) homesteads; b) community halls and squares, church and school halls, and open marketplaces; c) waiting places at community health facilities; d) the already existing social support systems, from family to community levels; e) the often used meeting places under trees. Beyond moving away from the resource scarcity fallacy, efforts that prioritize fostering a team spirit can also be crucial in reducing the mental health treatment gap6. These may include bringing together different relevant stakeholders at the community level, including any available mental health experts7, to engage in participatory dialogues on perceptions of mental illness; impact of mental health on individuals, their families and communities; and human rights and mental health. Dialogues can also identify perceived barriers to mental health care, such as stigma, and how these barriers can be overcome. Importantly, this approach promotes community ownership and responsibility for good mental health. Of course, the composition of dialogue will vary, but should – at the minimum – include patients, families, community opinion leaders, service providers and policy makers. How we think about recovery is also important. On the one hand, recovery can be defined to mean a complete disappearance of symptoms. On the other, it can mean a reduction of symptoms that allows the patient to engage in other equally pressing life priorities. Consider a mother who suffers from depression. She often must make an informed decision on whether to attend a clinical appointment or if she is feeling well enough to prioritize getting food for and taking care of her children8. Whereas a clinician may not consider her "recovered", she may consider herself "well enough" and "recovered" to make the informed decision to prioritize caring for her children. Thus, a contextual determination of recovery is important, because our conceptualization of the treatment gap is affected by how we define recovery. We believe that solutions to reduce the mental health treatment gap already exist in many LMICs. We have listed three possible strategies here. What gives us hope is that across our work we have demonstrated that these three strategies can feasibly allow us to deliver affordable, available, accessible and evidence-based mental health services, and to perhaps reduce the treatment gap to levels seen in HICs using the currently available resources3, 4. Of course, there are other strategies, such as promoting liaisons between different disciplines to provide a one-shop holistic and integrated approach to management of physical and mental comorbidities and associated psychosocial determinants; maximizing the integration of technology to increase access to mental health9; and collaborative LMIC and HIC research on cost-effective treatments, risk and protective factors – including biomarkers – and priorities in global mental health. If we rethink strategies and models and prioritize those that are innovative and context appropriate, we can reduce the treatment gap in LMICs with existing resources even as new resources continue to be developed.